Neuroscience Flashcards

Question

Recognise the presenting symptoms of meningitis.

Answer 1

- Severe headache - Photophobia - Neck or backache - Irritability - Drowsiness - Vomiting - High-pitched crying or fits (common in children) - Clouding of consciousness - Fever Check travel and exposure history: - Rodents - lymphocytic choriomeningitis virus - Ticks - Lyme borrelia, Rocky Mountain spotted fever - Mosquitoes - West Nile virus, St. Louis encephalitis virus - Sexual activity - HSV-2, HIV, syphilis - Travel - C.immitis, A.cantonensis - Contact with other individuals with vrial exanthems - enteroviruses

Answer 2

Signs of Meningism: - Photophobia - Neck stiffness - Kernig's sign - with hips flexed, pain / resistance on passive knee extension - Brudzinski's sign - flexion of hips on neck flexion Signs of Infection - Fever - Tachycardia - Hypotension - Skin rash - petechiae with meningococcal septicaemia - Altered mental state

Answer 3

1. Bloods 2. Imaging 3. Lumbar Punctre 4. viral 5. TB Bloods - 2 sets of blood cultures - do not delay antibiotics Imaging - CT scan to exclude a mass lesion or raised intracranial pressure before LP - LP may lead to cerebral herniation due to subsequent CSF removal - CT head before LP in patents with immunodeficiency, history of CNS disease, reduced consciousness, fit, focal nerologic deficit, papilloedema LP - Note opening CSF pressure - Send for microscopy with culture, sensitivity, Gram staining, biochemistry, cytology - Streptococcus pneumoniae - Gram-positive diplococcic - Neisseria Meningitidis - gram-negative diplococcic Bacterial - Cloudy CSF - Increased neutrophils - Increased protein - Reduced glucose - CSF serum glucose ratio of <0.5 Virus - Increased lymphocytes - Increased protein - Normal glucose TB - Fibrinous CSF - Increased lymphocytes - Increased protein - Reduced glucose Staining of petechiae scrapings may detect meningococcus in 70%. Additional studies - e.g. viral PCR, staining / culture for mycobacteria and fungi, HIV test depending on the clinical presentation / CSF findings.

Answer 4

1. IMMEDIATE ANTIBIOTICS IV or IM - If meningitis suspected before lumbar puncture or CT - 3rd generation cephalosporin - cefotaxime 2g QDS or ceftriaxone 2g BD - Benzylpenicillin - initial blind therapy, sensitive meningococci and pneumococci - Listeria = amoxicillin + gentamicin - Penicillin & Cephalosporin resistant pneumococci = + vancomycin + rifampicin - History of anaphylaxis to penicillin or cephalosporins = chloramphenicol - Patients treated with benzylpenicillin or chloramphenicol = 2 days rifampicin (eliminate nasopharyngeal carriage) 2. DEXAMETHASONE IV - 10mg QDS for 4 days - Given shortly before or with first dose of antibiotics - Continue in pneumococcal or H. influenzae meningitis - reduce complications of death (pneumococcal) and hearing loss (H.influenzae) - Avoid dexamethasone if HIV suspected 3. RESUSCITATION - ITU 4. PREVENTION - Notify public health services - Consult a consultant in communicable disease control for advice regarding chemoprophylaxis - e.g. rifampicin for 2 days - Vaccination for close contacts - Vaccination against meningococcal serogroups A and C (none for B)

Answer 5

- Septicaemia - Shock - DIC - Renal failure - Fits - Peripheral gangrene - Cerebral oedema - Cranial nerve lesions - Cerebral venous thrombosis - Hydrocephalus - Water house - Friderichsen Syndrome - bilateral adrenal haemorrhage

Answer 6

Bacterial meningitis mortality at 10-40% with meningococcal sepsis. In developing countries - higher mortality rate Viral meningitis - self-limiting

Answer 7

Arterial haemorrhage into the subarachnoid space.

Answer 8

- Rupture of a saccular aneurysms at the base of the brain - usually at Circle of Willis (85%). - Permesencephalic haemorrhage - e.g. parenchymal haemorrhages tracking onto surface of brain (10%) - Arteriovenous malformations - Bleeding diatheses - Vertebral or carotid artery dissection with intracranial extension - Mycotic aneurysms - Drug abuse - e.g. cocaine, amphetamines Associated with: - Hypertension - Smoking - Excess alcohol intake - Polycystic kidney disease - Marfan's Syndrome - Peseudoxanthoma elasticum - Ehlers-Danlos Syndrome

Answer 9

Incidence 10 in 100,000 | Peak incidence = 50-60 years

Answer 10

- Sudden onset severe headache - hit at the back of the head - Nausea - Vomiting - Neck stiffness - Photophobia - Reduced level of consciousness

Answer 11

Meningism - Neck stiffness - Kernig's sign - resistence or pain on knee extension when hip is flexes - Irritation of meninges by blood - Pyrexia GCS - Assess and regularly monitor for deterioration Increased intracranial pressure - Papilloedema - IV or III cranial nerve palsy - Hypertension - Bradycardia Fundoscopy - Subhyaloid haemorrhage - between retina and vitreous membrane Focal Neurological Signs - 2nd day - Ischaemia from vasospasm and reduced brain perfusion - Aneurysms - pressure on cranial nerves causing opthalmoplegia (III or VI nerve palsy)

Answer 12

- Bloods - FBC, U&E, ESR, CRP, Clotting (?bleeding diathesis) - CT - Angiography (CT or intra-arterial) - LP CT - Hyperdense area in basal regions of the skull - due to blood in subarachnoid space - Identifies any intraparenchymal or intraventricular haemorrhages Angiography - To detect the source of bleeding if the patient is a candidate for surgery or endovascular treatment LP - Increased opening pressure - Increased red cells - Few white cells - Xanthochromia - straw-coloured CSF due to Hb breakdown - Confirmed by spectrophotometry of CSF supernatant after centrifugation

Answer 13

A collection of blood that develops between the surface of the brain and the dura mater. Acute - within 72h Subacute - 3-20 days Chronic - 3 weeks

Answer 14

Trauma causing rapid acceleration and deceleration of the brain results in shearing forces which tear veins (bridging veins) that travel from the dura to the cortex. Bleeding occurs between the dura and arachnoid membranes. In children, non-accidental injury should always be considered.

Answer 15

Acute - Younger patients - Associated with major trauma (5-25% of cases in severe head injury) More common than extradural haemorrhage. Chronic - Elderly - 1-5 per 100,000

Answer 16

Acute - History of trauma with head injury - Patient has reduced conscious level Subacute - Worsening headaches 7-14 days after injury - Altered mental status Chronic - Headache - Confusion - Cognitive impairment - Psychiatric symptoms - Gait deterioration - Focal weakness - Seizures May not be a history of fall or trauma, hence low index of suspicion especially in elderly and alcoholics.

Answer 17

Acute - Low GCS - Midline shift haematoma - ipsilateral fixed dilated pupil (compression of ipsilateral third nerve parasympathetic fibres) - Pressure on brainstem results in reduced consciousness and bradycardia Chronic - Neurological examination may be normal - Focal neurological signs - III or VI nerve dysfunction, papilloedema, hemiparesis, reflex asymmetry

Answer 18

CT Head - Crescent or sickle-shaped mass - Concave over brain surface - extradural is lentiform in shape - CT appearance changes with time - Acute - hyperdense, become isodense over 1-3 weeks (presence may be inferred from effacement of sulci, midline shift, ventricular compression, obliteration of basal cisterns) - Chronic - hypodense - approach that of CSF MRI Brain - Higher sensitivity for isodense or small SDH

Answer 19

Acute - ALS protocol with priorities of cervical spine control and ABC - GCS, pupillary reactivity - If signs of raised ICP, head elevation and consider osmotic diuresis with mannitol or hyperventilation - Stabilise - then CT head Conservative - Especially if small and minimal midline shift - SDH <10 mm thickness - Midline shift <5mm Surgical Chronic - If symptomatic or mass effect on imaging - surgical treatment with Burr hole, craniotomy, drainage (24-72h) - If asymptomatic or no significant mass effect - conservative management, serial imaging to monitor for spontaneous resorption - May require craniotomy with membranectomy if haematoma does not fully liquify Children - Percutaneous aspiration via open fontanelle - Placement of subdural to peritoneal shunt

Answer 20

- Raised ICP - Cerebral oedema - Secondary ischaemic brain damage - Mass effect - transtentorial or uncal herniation Post-Op - Seizures - Recurrence (33% for SDH) - Intracranial haemorrhage - Subdural empyema - Brain abscess - Meningitis - Tension pneumocephalus

Answer 21

Acute - Underlying brain injury most important factor on outcome Chronic - Generally better outcome than acute - Lower incidence of underlying brain injury - Good outcomes in 3/4 of those treated by surgery

Answer 22

A brain tumour is an abnormal growth occuring in any tissue contained within the cranium, including the brain, cranial nerves, meninges, skull, pituitary gland and pineal gland. May be benign or malignant and originate from within the cranium (primary) or from a metastatic tumour found elsewhere (secondary). Present with signs of raised ICP and gait abnormality. Meningioma: - Primary tumour of cranial and spinal compartments ``` Acoustic Neuroma (Vesticular Schwannoma): - Benign, slow-growing cerebellopontine angle tumour that grows from the superior vestibular component of the vestibulocochlear nerve ``` Medulloblastoma: - Malignant, invasive brain tumour arising from cerebellar vermis Astrocytic Brain Tumours: - Primary tumour of the brain arising from astrocytes, which are an important part of the blood-brain barrier - A neuroepithelial type tumour categorised by histological type and grade with each subtype having different age-adjusted incidence rate, behaviour and clinical course Craniopharyngioma: - Benign extra-axial non-glial epithelial tumours of the CNS Acromegaly: - Due to pituitary somatotroph adenoma in 99% of cases Cushing's Disease : - Hypercortisolism caused by an ACTH-secreting pituitary adenoma Prolactinoma: - Benign, prolactin-expressing and secreting pituitary adenoma

Answer 23

``` Acoustic Neuroma (Vesticular Schwannoma): - Neurofibromatosis Type 2 - autosomal dominant ``` Craniopharyngioma: - Arise within the sellar / suprasellar space Primary CNS lymphoma: - Immunosuppression - HIV infection - EBV infection Non-functional pituitary adenoma: - Multiple endocrine neoplasia Type 1 (MEN-1) Acromegaly: - Pituitary somatotroph adenomas chronically secrete excessive GH - Stimulates IGF-1 production

Answer 24

Meningioma: - Represent over 36% of primary brain tumours, 53.5% of all non-malignant tumours - More common in women and usually benign Medulloblastoma: - Usually in first 2 decades of life - Common brain tumours of childhood Astrocytic Brain Tumours: - Common in industrial countries - White males Craniopharyngioma: - Both children and adults - Presents at any age - Bimodal age distribution - peak between 5-14 years and 50-70 years Primary CNS lymphoma: - <1% of all non-Hodgkin's lymphoma - Uncommon Prolactinoma: - Women during childbearing years

Answer 25

Meningioma: - Neurological deficit - Progressive, focal or general headaches in large tumours - Visible bony growth Acoustic Neuroma (Vesticular Schwannoma): - Unilateral sensorineural hearing loss - Found on routine hearing examinations - Progressive dizziness - Unilateral facial numbness Medulloblastoma: - Due to mass effect from tumour or due to obstructive hydrocephalus - Morning headaches - Nausea - Vomiting (relieving headaches) - Diplopia - 6th nerve palsy - Ataxia Astrocytic Brain Tumours: - Focal neurological defecits according to location - Signs of raised ICP Craniopharyngioma: - Mass effect symptoms - Visual loss - Symptoms of ICP - Pituitary dysfunction - Children - growth failure - Adults - diabetes insipidus and sexual dysfunction Non-functional pituitary adenoma: - Features of hormonal insufficiency - Longstanding and progress slowly Prolactinoma: - Hyperprolactinaemia - Hypogonadism - Sexual dysfunction - Galactorrhoea - Hypopituitarism - Osteoporosis

Answer 26

PITUITARY MASS ASSESSMENT - 2 type - Clinically Non-functional Adenoma (CNFA) - no hypersecretion of hormone - Functional Adenoma - hypersecretion of hormone Functional: - Acromegaly - Cushing's disease - Prolactinoma Compression of adjacent structures: - Visual disturbances - Ophthalmoplegia - Headaches ACUTE HEADACHE ASSESSMENT: - Most with a benign diagnosis - HIgh index of suspicion - Brain tumours causing headaches seen on non-enhancing contrast CT - 0.7-1.3% of all paeds emergency visits - 62% of patients with childhood brain tumours have a headache, 98% have 1 neurological symptom on exam ATAXIA ASSESSMENT: - Hereditary or acquired - Cerebellar, sensory or vestibular - Extensive list of acquired causes - e.g. vascular, demyelinating, neoplastic, autoimmune, toxic, degenerative, compressive, infectious aetiologies HYPERPROLACTINAEMIA - Prolactinomas - micro or macroadenomas - Acromegaly - Interruption of the hypothalamic-pituitary axis SHORT STATURE - Craniopharyngioma - Cushing's syndrome during childhood - Symptoms of Craniopharyngioma: Diplopia, vision loss, headache, short stature

Answer 27

Meningioma: - MRI with and without contrast enhancement - Asymptomatic lesions followed up with serial observation ``` Acoustic Neuroma (Vesticular Schwannoma): - Gadolinium-enhanced MRI ``` Medulloblastoma: - Cranial CT and MRI Astrocytic Brain Tumours: - Cranial imaging with surgical biopsy Craniopharyngioma: - Crania CT / MRI - Full endocrine evaluation Primary CNS lymphoma: - Cranial CT - Clinical history - LP & CSF analysis Non-functional pituitary adenoma: - Endocrine evaluation - Cranial imaging Acromegaly: - IGF-1 hypersecretion biochemical confirmation Cushing's Disease : - Demonstration of unsuppressed ACTH - Cranial MRI Prolactinoma: - Assessment of serum prolactin levels - Cranial imaging

Answer 28

A disorder that causes pain in the lower back and hip, which radiates down the back of the thigh into the leg. Describes a predictable constellation of symptoms occuring secondary to mechanical and/or inflammatory cycles compromising at least one of the lumbosacral nerve roots.

Answer 29

Damage caused by compression fo nerve roots exiting spine at levels L1-S4. Most disc herniations occur posterolaterally, root that gets compressed is actually the root that exists the foramen below the herniated disc. Protrusion at L4/L5 will compress L5 root, protrusion at L5/S1 will compress S1 root. Most common in lower back and neck = lumbar-sacral, cervical. Majority of cases are benign and will resolve spontaneously. Risk factors: - Activities placing an excessive or repetitive load on spine - Heavy labour - Contact sports - Age 45-64 yrs - Smoking - Mental stress - Frequent lifting - Driving - vibration of whole body Causes: - Lesions of intervertebral discs and degenerative disease of spine - Herniated disc with nerve root compression - Tumours - Congenital abnormalities - Scoliosis - Osteomyelitis

Answer 30

3-5% prevalence rate.

Answer 31

- Tingling - Radiating pain - Numbness - Paraesthesia - Shooting pain - Gait abnormalities - Predictable patterns affecting corresponding dermatome or myotome. Sciatica: - Unilateral leg pain greater than lower back pain - Leg pain follows dermatomal pattern - Pain traveling below knee to foot or toes - Numbness and paraesthesia - Straight leg raise positive - induces more pain

Answer 32

- Tingling - Radiating pain - Numbness - Paraesthesia - Shooting pain - Gait abnormalities - Predictable patterns affecting corresponding dermatome or myotome. Sciatica: - Unilateral leg pain greater than lower back pain - Leg pain follows dermatomal pattern - Pain traveling below knee to foot or toes - Numbness and paraesthesia - Straight leg raise positive - induces more pain

Answer 33

DDX: - Radicular syndrome/ sciatica - Pseuoradicular syndrome - Thoracic disc injuries - Low back pain - Cauda equina - Inflammatory / metabolic causes - e.g. diabetes, ankylosing spondylitis, Paget's disease, Arachnoiditis, Sarcoidosis - Trochanteric bursitis - Intraspinal synovial cysts CXR - presence of trauma or osteoarthritis, signs of tumour or infection EMG - detect radiculopathies, limited utility in diagnosis MRI - see if disc herniation and nerve root compression are present

Answer 34

An acute unilateral peripheral facial nerve palsy in patients for whom physical examination and history are otherwise unremarkable, consisting of deficits affecting all facial zones equally that fully evolve within 72 hours. DIAGNOSIS OF EXCLUSION. Facial palsy of an otherwise known aetiology (e.g., Lyme disease-associated facial palsy), or facial palsy that is progressive, waxing and waning, or affects facial zones in an uneven fashion, is not Bell's palsy..

Answer 35

Acute unilateral facial palsy of probable viral aetiology. Risk factors: - Intranasal influenza vaccination - Pregnancy - URTI - Black or Hispanic ancestry - Arid / cold climate - HTN - Family history - Diabetes

Answer 36

Most population studies generally show an annual incidence of 15–30 cases per 100,000 population. Bell palsy is thought to account for approximately 60–75% of cases of acute unilateral facial paralysis, with the right side affected 63% of the time. It can also be recurrent, with a reported recurrence range of 4–14%

Answer 37

- Single episode - Unilateral - Absence of constitutional symptoms - Involvement of all facial nerve branches - Keratoconjunctivitis sicca (dry eye) - Pain - Synkinesis (late Bell's palsy) - involuntary and abnormal synchronous movement - Any age - Hyperacusis - unusual sensitivity to sound ipsilateral to facial palsy due to insult to branchial efferents of stapedius muscle - Dysgeusia - taste disturbance of ipsilateral anterior 2/3rds of tongue

Answer 38

- Single episode - Unilateral - Absence of constitutional symptoms - Involvement of all facial nerve branches - Keratoconjunctivitis sicca (dry eye) - Pain - Synkinesis (late Bell's palsy) - involuntary and abnormal synchronous movement - Any age - Hyperacusis - unusual sensitivity to sound ipsilateral to facial palsy due to insult to branchial efferents of stapedius muscle - Dysgeusia - taste disturbance of ipsilateral anterior 2/3rds of tongue

Answer 39

1st Line: - Clinical diagnosis - acute unilateral facial palsy with a normal physical examination - ENoG (evoked eEMG) - >90% decrease in amplitude of compound muscle action potential (CMAP) - Needle EMG - absence of voluntary motor unit potentials - Serology for Borrelia burgdorferi - negative Consider: - Pure-tone audiometry - normal - Tympanometry and stapedius reflex - absent or impaired reflex of the ipsilateral efferent limb - MRI gadolinium-enhanced fine cut of facial nerve course - post-contrast enhancement of distal meatal, labyrinthine, geniculate, and sometimes tympanic and mastoid segments of facial nerve, without enlargement - CT fine-cut, non-enhanced - normal

Answer 40

CORTICOSTEROID - Prednisolone OD within 72h of symptoms onset EYE PROTECTION as keratoconjunctivitis may lead to exposure keratopathy - glasses worn, artificial tears used as needed, ophthalmic lubricant and eyelid taped closed, eye patching avoided. If severe palsy / complete paralysis on presentation: - Concurrent antiviral therapy - e.g. valaciclovir, aciclovir - Surgical decompression

Answer 41

- Irreversible damage - Abnormal regrowth and healing - Involuntary contraction - synkinesis

Answer 42

Complete recovery to normal facial function occurs in approximately 70% of untreated cases, with permanently impaired facial function occurring to a minor degree in 13% and to a major degree in 16% of cases. Onset of clinical recovery is nearly always demonstrated within 4 to 6 months of symptom onset; absence of any return of hemi-facial tone or movement by this time is highly suggestive of an alternative diagnosis.

Answer 43

An attack of severe pain localised to the unilateral orbit, supra-orbital and/or temporal areas that lasts from 15 mins to 3 hours. Occurs once every other day to 8 times a day. Attacks occur at the same time period for several weeks = cluster period. Accompanied by ipsilateral autonomic signs (secondary to parasympathetic HYPERactivity and sympathetic HYPOactivity) and restlessness. (Migraine = motion sensitivity presentation) Both cluster bouts and attacks during a cluster period can show cyclical periodicity occurring at the same time of year or the same time of day.

Answer 44

- Hypothalamic activation with secondary trigeminal and autonomic activation - Precipitated by alcohol, volatile smells, warm temperatures and sleep Risk factors: - Male sex - Family history - Head injury - Cigarette smoking - Heavy drinking

Answer 45

Cluster headache is a primary headache disorder affecting up to 0.1% of the population. Approximately 90% of patients have episodic cluster headache, which consists of at least two cluster periods of attacks lasting from 7 days to 1 year when untreated (cluster periods usually last from 2 weeks to 3 months), separated by remission periods lasting at least 3 months. The chronic form of cluster headache is seen in approximately 10% of patients and consists of attacks that occur for 1 year or longer without remission, or with remission periods lasting less than 3 months.[1][2] The condition may be chronic from onset or may evolve over time from the episodic form.

Answer 46

Occurs once every other day to 8 times a day. Lasts from 15mins-3 hours. Attacks occur at the same time period for several weeks = cluster period. Accompanied by ipsilateral autonomic signs (secondary to parasympathetic HYPERactivity and sympathetic HYPOactivity) and restlessness. (Migraine = motion sensitivity presentation) Both cluster bouts and attacks during a cluster period can show cyclical periodicity occurring at the same time of year or the same time of day. Autonomic features: - Ptosis - Conjunctival injection - Lacrimation - Rhinorrhoea - Nasal stuffiness - Eyelid and facial swelling - Aural fullness - Facial sweating - Redness Also associated with N&V, photophobia, phonophobia and migrainous aura.

Answer 47

Occurs once every other day to 8 times a day. Lasts from 15mins-3 hours. Attacks occur at the same time period for several weeks = cluster period. Accompanied by ipsilateral autonomic signs (secondary to parasympathetic HYPERactivity and sympathetic HYPOactivity) and restlessness. (Migraine = motion sensitivity presentation) Both cluster bouts and attacks during a cluster period can show cyclical periodicity occurring at the same time of year or the same time of day. Autonomic features: - Ptosis - Conjunctival injection - Lacrimation - Rhinorrhoea - Nasal stuffiness - Eyelid and facial swelling - Aural fullness - Facial sweating - Redness Also associated with N&V, photophobia, phonophobia and migrainous aura.

Answer 48

1st Line: - Brain CT or MRI - normal in primary, abnormal in secondary (tumour, cavernous sinus pathology) - ESR - normal in primary - Pituitary function tests - normal in primary, abnormal in secondary (pituitary adenoma) Consider: - Polysomnogram - abnormal with sleep apnoea - ECG - normal, conduction abnormalities or evidence of ischaemiac changes (check drug prescription)

Answer 49

An acute inflammatory polyneuropathy. Classified according to symptoms. = AXONAL AND DEMYELINATING FORMS.

Answer 50

Associated with outbreaks of ZIKA. 2/3rds of patients have a history of gastroenteritis or influenza-like illness weeks before onset of neurological symptoms. Risk factors: - Preceding viral illness - Preceding bacterial infection - Preceding mosquito-borne viral infection - Hepatitis E infection - Immunisation - Cancer and lymphoma - Older age - HIV infection - Male

Answer 51

Up to 30% will develop respiratory muscle weakness requiring ventilation. Neurophysiology is confirmatory and is abnormal in 85% of patients, even early in the disease. Most common variant = acute inflammatory demyelinating polyradiculoneuropathy. GBS occurs throughout the world with a median annual incidence of 1.3 cases per population of 100 000, with men being more frequently affected than women. GBS is considered to be an autoimmune disease triggered by a preceding bacterial or viral infection.

Answer 52

- Muscle weakness - Respiratory distress - Speech problems - Paraesthesia - Back / leg pain - Areflexia / hyporeflexia - Facial weakness - Bulbar dysfunction causing oropharyngeal weakness - Extra-ocular muscle weakness - Facial droop - Diplopia - Dysarthria - Dysphagia - Dysautonomia - Anisocoria - Non-reactive pupil - Opthalmoplegia

Answer 53

Clincal Definition: - Motor difficulty - Hyporeflexia - Paraesthesias without objective sensory loss - Increased cerebrospinal fluid albumin with absence of cellular reaction = albuminocytological dissociation - Muscle weakness - Respiratory distress - Speech problems - Paraesthesia - Back / leg pain - Areflexia / hyporeflexia - Facial weakness - Bulbar dysfunction causing oropharyngeal weakness - Extra-ocular muscle weakness - Facial droop - Diplopia - Dysarthria - Dysphagia - Dysautonomia - Anisocoria - Non-reactive pupil - Opthalmoplegia

Answer 54

1st Line: - Nerve conduction studies - slow - LP - high protein, normal/high lymphocytes - LFTs - high AST, high ALT, high bilirubin (not enough to cause jaundice) - Spirometry - LOW vital capacity, LOW max inspiratory pressure, LOW max expiratory pressure - Antiganglioside antibody Consider: - Serology - presence of Campylobacter jejuni, CMV, EBV, Mycoplasma pneumoniae, H.influenzae - Stool culture - Campylobacter jejuni, poliovirus (pure motor syndrome) - HIV antibodies - Spinal MRI - enhancement of cauda equina nerve roots with gadolinium - Borrelia burgdorferi serology (Lyme disease) - CSF meningococcal PCR - CSF cytology - positive in carcinomatous meningitis - CSF ACE - positive in sarcoidosis - CXR - bilateral hilar lymphadenopathy (sarcoidosis) - CSF VDRL (neurosyphilis) - CSF West Nile PCR

Answer 55

Characterized by 4 signs: - Miosis - constricted pupil - Ptosis - drooping of upper eyelid - Anhidrosis - absence of sweating of the face - Enopthalmos - sinking of eyeball into orbit

Answer 56

Causes: - Brainstem / Cervical spinal cord = tumour (glioma), infarction, syringomyelia / bulbia - T1 root = brachial plexus lesion, neurofibromatosis - Cervical sympathetic chain = Pancoast tumour (lung apex) - Internal carotid artery = dissection, occlusion - Migraine - Cluster headaches CHILDREN: - Injury to the neck or shoulders during delivery - Defect of the aorta present at birth - Tumor of the hormonal and nervous systems (neuroblastoma)

Answer 57

Uncommon, occurring with a frequency of approximately 1 per 6,000.

Answer 58

Characterized by 4 signs: - Miosis - constricted pupil - Ptosis - drooping of upper eyelid - Anhidrosis - absence of sweating of the face - Enopthalmos - sinking of eyeball into orbit Presents with: - A persistently small pupil (miosis) - A notable difference in pupil size between the two eyes (anisocoria) - Little or delayed opening (dilation) of the affected pupil in dim light - Drooping of the upper eyelid (ptosis) - Slight elevation of the lower lid, sometimes called upside-down ptosis - Sunken appearance to the eye (enopthalamos) - Little or no sweating (anhidrosis) either on the entire side of the face or an isolated patch of skin on the affected side CHILDREN: - Lighter iris color in the affected eye of a child under the age of 1 - Lack of redness (flushing) on the affected side of the face that would normally appear from heat, physical exertion or emotional reactions

Answer 59

Characterized by 4 signs: - Miosis - constricted pupil - Ptosis - drooping of upper eyelid - Anhidrosis - absence of sweating of the face - Enopthalmos - sinking of eyeball into orbit

Answer 60

- Apraclonidine or Cocaine Drop Testing - little dilation fo affected eye if caused by 3rd order neuron (neck & above lesion) - MRI - Carotid USS - CXR - CT - CXR Investigate causes to locate abnormality causing Horner's Syndrome.

Answer 61

Treat the cause.

Answer 62

Depends on cause.

Answer 63

Horner's Syndrome disappears when an underlying medical condition is effectively treated

Answer 64

The procedure of taking fluid from the spine in the lower back through a hollow needle, usually done for diagnostic purposes.

Answer 65

DIAGNOSTIC - CNS infection - Autoimmune CNS diseases like GBS - CNS vasculitis - CT negative SAH - Malignant cells in metastasis - Injection of dye like fluorescin to identify site of CSF leakage THERAPEUTIC - Benign intracranial hypertension - Acute communicating hydrocephalus - Cryptococcal meningitis in HIV infections - For CSF leaks DELIVERY OF DRUGS - Antibodies - Anti-neoplastic drugs

Answer 66

- Space-occupying lesion with mass effect - increased ICP / CSF pressure (can lead to cerebral herniation) - Posterior fossa mass - Arnold-Chiari malformation - Anticoagulant medication - Coagulopathy - Uncorrected bleeding diathesis - Congenital spine abnormality - Skin infection at puncture site

Answer 67

A slowly progressive, neurodegenerative disorder characterised by: - Chorea - Incoordination - Cognitive decline - Personality changes - Psychiatric symptoms Culminates in: - Immobility - Mutism - Inanition

Answer 68

AUTOSOMAL DOMINANT. Trinucleotide repeat disorder. Risk factors: - Expansion of the CAG repeat length at the N-terminal end of the Huntingtin Gene - Family history

Answer 69

Affects men and women equally. | Characteristically in mid-adult life, but can occur at any age.

Answer 70

- Positive FHx of Huntington's disease - Known expansion of the CAG repeat length at the N-terminal end of the Huntingtin gene - Impaired work or school performance - Personality change - Irritability and impulsivity - Chorea - random movements of fingers and toes with peculiar postures of hands, trunk or limbs, odd facial expressions - Twitching or restlessness - Loss of coordination - dropping things, stumbling, motor vehicle accidents - Deficit in fine motor co-ordination - Slowed rapid (saccadic) eye movements - Motor impersistence - trouble maintaining maximal protrusion of tongue or lid closure, milkmaid's grip (variation in intensity of requested squeeze) - Impaired tandem walking - Apathy - Depression, obsessions and compulsions

Answer 71

- Positive FHx of Huntington's disease - Known expansion of the CAG repeat length at the N-terminal end of the Huntingtin gene - Impaired work or school performance - Personality change - Irritability and impulsivity - Chorea - random movements of fingers and toes with peculiar postures of hands, trunk or limbs, odd facial expressions - Twitching or restlessness - Loss of coordination - dropping things, stumbling, motor vehicle accidents - Deficit in fine motor co-ordination - Slowed rapid (saccadic) eye movements - Motor impersistence - trouble maintaining maximal protrusion of tongue or lid closure, milkmaid's grip (variation in intensity of requested squeeze) - Impaired tandem walking - Apathy - Depression, obsessions and compulsions

Answer 72

1st Line: - No initial tests Consider: - CAG repeat testing - a positive result is >40 CAG repeats on 1/2 alleles, intermediate is 36-39 repeats - MRI or CT scan - evident caudate or striatal atrophy

Answer 73

A condition in which fluid accumulates in the brain, typically in young children, enlarging the head and sometimes causing brain damage. Excess CSF builds up within the fluid-containing cavities or ventricles of the brain. 3 TYPES: - Congenital hydrocephalus - Acquired hydrocephalus - Normal pressure hydrocephalus - usually older people 2 TYPES: - Communicating hydrocephalus - when the flow of CSF is blocked after it exits the ventricles - Non-communicating hydrocephalus

Answer 74

Abnormal accumulation of CSF in ventricles caused by: 1) Impaired outflow of CSF from ventricles (Obstructive) - Lesions of third ventricle, fourth ventricle, cerebral aqueduct - Posterior fossa lesions - e.g. tumour, blood compressing the 4th ventricle - Cerebral aqueduct stenosis 2) Impaired CSF resorption in subarachnoid villi (Non-Obstructive) - Tumours - Meningitis - typically TB - Normal pressure hydrocephalus COMMUNICATING HYDROCEPHALUS - The flow of CSF is blocked after it exits the ventricles - CSF can still flow between ventricles - passages between ventricles remain open - Reduced flow and absorption of CSF into arachnoid villi NON COMMUNCATING HYDROCEPHALUS - The flow of CSF is blocked along one or more of the narrow passages connecting the ventricles HYDROCEPHALUS EX-VACUO - described apparent enlargement of ventricles, but this is compensatory change due to brain atrophy - Brain damage caused by stroke or injury - Tissue around ventricles shrink - ventricles become bigger than normal - Not a true hydrocephalus NORMAL PRESSURE HYDROCEPHALUS (NPH) - Result of bleeding into brain CSF via subarachnoid or intraventricular haemorrhage, head trauma, infection, tumour or surgical complication - Many people develop when none of these factors are present - Increase in CSF occurs slowly enough for tissue around ventricles to compensate - Fluid pressure within the head does not increase - Causes problems with walking, bladder control and difficulties thinking and reasoning - Mistaken for Alzheimer's CONGENITAL HYDROCEPHALUS - Inherited genetic abnormalities that block the flow of CSF - Developmental disorders - Complications of premature birth - bleeding within ventricles - Infection during pregnancy - e.g. rubella ACQUIRED HYDROCEPHALUS: - Brain or spinal cord tumorus - Infections of CNS - e.g. bacterial meningitis - Injury or stroke that causes bleeding in the brain

Answer 75

Bimodal age distribution. | Congenital malformations and tumours in the young, tumourd and strokes in the elderly.

Answer 76

- Headache - Blurred or double vision - Nausea or vomiting - Problems with balance - Slowing or loss of developmental progress like walking or talking vision problems - Decline in school or job performance - Poor coordination - Loss of bladder control and/or frequent urination - Difficulty remaining awake or waking up - Sleepiness - Irritability - Changes in personality or cognition including memory loss - Problems walking, often described as feet feeling "stuck" - Progressive mental impairment and dementia - General slowing of movements Obstructive - acute drop in conscious level, diplopia. NPH - chronic cognitive decline, falls, urinary incontinence.

Answer 77

- Unusually large head size - Rapidly increasing head circumference - Bulging and tense fontanelle or soft spot - Prominent scalp veins - Downwards deviation of eyes = 'sunset sign' - Unsteady walk or gait - Difficulty focusing the eyes - Sudden falls OBSTRUCTIVE - Impaired GCS - Papilloedema - CN VI nerve palsy - false localising sign of increased ICP NON-OBSTRUCTIVE - Cognitive impairment - Gait apraxia (shuffling) - Hyper-reflexia

Answer 78

CT - 1st line to detect hydrocephalus - Detect cause - e.g. tumour in brainstem CSF - Obtained from ventricular drains or lumbar puncture - Underlying pathology - e.g. tuberculosis - Check MC&S, protein, glucose (CSF and plasma) LP - Contraindicated in OBSTRUCTIVE as can cause tonsilar herniation and death - May be necessary in NPH as therapeutic trial

Answer 79

A chronic, genetically determined, episodic neurological disorder that usually presents early-to-mid-life. Migraine aura - a complex of reversible visual, sensory or speech symptoms that may precede or occur during headache - 15-30% of patients.

Answer 80

Menstrual migraine - most likely to occur in the 2 days leading up to a period and in the first 3 days of a period. Risk factors: - Family history - High caffeine intake - Exposure to change in barometric pressure - Female sex - Obesity - Stressful life events - Overuse of headache medications - Sleep disorders - Low socio-economic status - Allergies or asthma - Hypertension - Hypothyroidism - Diet

Answer 81

Scholarly articles for epidemiology of migraine The epidemiology of migraine - ‎Lipton - Cited by 285 An update on the epidemiology of migraine - ‎Lipton - Cited by 235 Epidemiology of migraine - ‎Silberstein - Cited by 113 Migraine is the third most common disease in the world (behind dental caries and tension-type headache) with an estimated global prevalence of 14.7% (that's around 1 in 7 people). Migraine is more prevalent than diabetes, epilepsy and asthma combined. Chronic migraine affects approximately 2% of the world population.

Answer 82

- Nausea - Photophobia - Phonophobia - Disability - Headache - Aurea - Vomiting - Unilateral - Throbbing sensation

Answer 83

- Nausea - Photophobia - Phonophobia - Disability - Headache - Aurea - Vomiting - Unilateral - Throbbing sensation

Answer 84

No lab or imaging tests are essential for diagnosis. 1st Line: - Clinical diagnosis - ICHD-3b criteria for migraine Consider: - ESR - normal (high in temporal arteritis) - LP - normal - CSF culture - normal - MRI brain - normal (SOL or ischaemic lesions identified) - CT head - normal (SOL or ischaemia or subarachnoid haemorrhage identified)

Answer 85

Involves identifying and avoid trigger factors, and the use of medication to treat the acute attack or prevent future attacks. Present to ED: - Rescue therapy - a) metoclopramide / prochlorperazine + diphenhydramine, b) promethazine, c) cumatriptan, d) ketorolac, e) valproic acid, f) haloperidol, g) paracetamol, h) magnesium sulfate - High-flow O2 - IV corticosteroid - dexamethasone - Secobarbital post-discharge Mild-Moderate, Non-Pregnant: - NSAID - aspirin, diclofenac potassium, ibuprofen, naproxen, celecoxib, indometacin - Anti-emetic - metoclopramide, prochlorperazine, promethazine - Hydration - Paracetmol monotherapy - Anti-emetic - Hydration - Paracetamol / Aspirin / Caffeine Severe, Non-Pregnant: - Triptan - almotriptan, eletriptan, rizatriptan, sumatriptan zolmitriptan, frovatriptan, naratriptan - Anti-emetic - metoclopramide, prochlorperazine, promethazine - Hydration - NSAID - aspirin, diclofenac potassium, ibuprofen, naproxen, celecoxib, indometacin - Ergot alkaloid - dihydroergotamine, ergotamine / caffeine - Corticosteroid - prednisolone, dexamethasone - Butalbital-containing compounds PREGNANT - Paracetamol - Anti-emetic - metoclopramide, prochlorperazine,promethazine - Hydration - Magnesium sulfate Other options: - Trigger avoidance - regular meals, good sleep hygiene, avoid volume depletion, regular exercise - Behavioural modification - Cycle control - Prevention with magnesium, triptan, anticonvulsant, TCA, beta-blocker, calcium-channel blocker, anti-depressant, calcitonin gene-related peptide inhibitor, botulinum toxin A - dependent on the number of headaches per month

Answer 86

Migraine is a chronic disorder with episodic attacks with a highly variable long-term prognosis. In many, migraine may have a very benign (complete remission) or relatively benign (partial remission) prognosis. In some, migraine persists and in others, it progresses.

Answer 87

A neurodegenerative disorder characterised by progressive muscle weakness that can start in limb, axial, bulbar or respiratory muscles and then generalises relentlessly, causing progressive disability and ultimately death, usually from respiratory failure.

Answer 88

Types of presentations: - Limb-onset - Bulbar-onset - Respiratory-onset Risk factors: - Genetic predisposition or family history - Age > 40 years - Military service - Professional athletic activity - Cigarette smoking - Agricultural chemical exposure - Lead exposure

Answer 89

Amyotrophic lateral sclerosis (ALS) develops with a uniform frequency in major Western countries; the annual incidence is about 2 per 100,000 population. The estimated prevalence is 5 per 100,000 in the United States; approximately 30,000 Americans currently have the disease.

Answer 90

Combination of upper motor neurone and lower motor neurone signs.

Answer 91

Combination of upper motor neurone and lower motor neurone signs. - Presence of risk factors - Upper extremity weakness - Stiffness, with poor co-ordination and balance - Spastic, unsteady gait - Painful muscle spasms - Difficulties in arising from chairs and climbing stairs - Foot drop - Stiffness and decreased balance with impact on gait - Head drop - Progressive difficulties in maintaining erect posture, with stooping - Muscle atrophy - Increased lumbar lordosis and tendency for abdominal protuberance - Hyper-reflexia - Dyspnoea - Coughing and choking on liquids (including secretions) and eventually on food - Strained, slow speech - Slurred, nasal, and dysphonic speech - Propensity for falls - Sialorrhoea and drooling - Inappropriate bursts of crying or laughing - Cognitive impairment - Features of frontotemporal dementai

Answer 92

Combination of upper motor neurone and lower motor neurone signs. - Presence of risk factors - Upper extremity weakness - Stiffness, with poor co-ordination and balance - Spastic, unsteady gait - Painful muscle spasms - Difficulties in arising from chairs and climbing stairs - Foot drop - Stiffness and decreased balance with impact on gait - Head drop - Progressive difficulties in maintaining erect posture, with stooping - Muscle atrophy - Increased lumbar lordosis and tendency for abdominal protuberance - Hyper-reflexia - Dyspnoea - Coughing and choking on liquids (including secretions) and eventually on food - Strained, slow speech - Slurred, nasal, and dysphonic speech - Propensity for falls - Sialorrhoea and drooling - Inappropriate bursts of crying or laughing - Cognitive impairment - Features of frontotemporal dementai

Answer 93

1st line: - Clinical diagnosis - presence of upper and lower motor neurone signs, disease progression, absence of any other explanation for presentation Consider: - EMG - diffuse, ongoing, chronic denervation - Repetitive nerve stimulation - only modest decreases in compound motor action amplitude after repetitive stimuli - MRI brain and spine - normal - Anti-GM1 antibodies - usually negative - Voltage-gated calcium-channel antibodies - negative (rule out Lambert-Eaton syndrome) - ACh receptor antibodies - negative (rule out myasthenia gravis) - Vitamin B12 - normal - Creatine kinase - max 1000 units/L in ALS, higher = alternative diagnosis - LP - normal - HIV test - negative or positive - Genetic testing - may be positive for mutations in C9orf72, SOD1, TARDBP and FUS

Answer 94

An inflammatory demyelinating disease characterised by the presence of episodic neurological dysfunction in at least two areas of the CNS (brain, spinal nerve, optic nerves) separated in time and space.

Answer 95

Unknown. Autoimmune basis with postulated environmental trigger in a genetically susceptible individual. Immune-mediated damage to CNS myelin results in impaired conduction along axons. Associated grey matter atrophy. Risk factors: - Female sex - Northern latitude - Genetic factors - Smoking - Vitamin D deficiency - Autoimmune disease - EBV

Answer 96

White women Age 20-40 years May affect either sex and any age or ethnic group, and may have variable neurological symptom location and/or duration.

Answer 97

Depends on site of inflammation. Optic neuritis - unilateral deterioration in visual acuity and colour perception, pain on eye movement. Sensory system - pins and needles, numbness, burning. Motor - limb weakness, spasms, stiffness, heaviness. Autonomic - urinary urgency, hesitancy, incontinence, impotence. Psychological - depression, psychosis. Uhthoff's phenomenon - transient increase or recurrence of symptoms due to conduction block precipitated by a rise in body temperature. - Visual disturbance in one eye - Peculiar sensory phenomena - Female sex - Ages 20-40 years - Foot dragging or slapping - Leg cramping - Fatigue - Urinary frequency - Bowel dysfunction - Spasticity / increased muscle tone - Increased deep tendon reflexes - Imbalance / inco-ordination - Pale optic disc or non-correctable visual loss - Incorrect responses to Ishihara colour blindness test plates - Abnormal eye movements

Answer 98

Optic neuritis - impaired visual acuity, loss of coloured vision, swollen optic nerve head (acute), optic atrophy (chronic). Visual field testing - central scotoma, field defects. Relative afferent pupillary defect - both pupils contract when light is shone on unaffected side, both pupils dilate when light is swung to the diseased eye. Internuclear ophthalmoplegia - lateral horizontal gaze produces a failure of adduction of the contralateral eye, indicating lesion of contralateral medial longitudinal fasciculus. Sensory - paraesthesia (vibration and joint position sense loss more common than pain and temperature). Motor - UMN signs Cerebellar - limb ataxia (intention tremor, past pointing, dysmetria), dysdiadochokinesis, ataxic wide-based gait, scanning speech. Lhermitte's Phenomenon - electric shock-like sensation in arms and legs precipitated by neck flexion. - Visual disturbance in one eye - Peculiar sensory phenomena - Female sex - Ages 20-40 years - Foot dragging or slapping - Leg cramping - Fatigue - Urinary frequency - Bowel dysfunction - Spasticity / increased muscle tone - Increased deep tendon reflexes - Imbalance / inco-ordination - Pale optic disc or non-correctable visual loss - Incorrect responses to Ishihara colour blindness test plates - Abnormal eye movements

Answer 99

1st line: - MRI brain - hyperintensities in periventricular white matter - MRI spinal cord - demyelinating lesions in spinal cord - FBC - normal - Comprehensive metabolic panel - normal - TSH - normal - Vitamin B12 - normal Consider: - Anti-neuromyelitis optica antibody - present in neuromyelitis optica (Devic syndrome) - Cerebrospinal fluid evaluation - glucose, protein and cell count normal, oligoclonal bands and high CSF IgG and IgG synthesis rates in 80% of MS - Evoked potentials - prolongation of conduction

Answer 100

A chronic autoimmune disorder of the post-synaptic membrane at the neuromuscular junction in skeletal muscle. NB: Lambert-Eaton myasthenic syndrome subtype - caused by auto-antibodies against presynaptic calcium ion channels impairing ACh release.

Answer 101

Circulating antibodies against nAChR and associated proteins impair transmission. Elevated serum acetylcholine receptor antibody titres or muscle-specific tyrosine kinase antibodies are present. Antibodies to 4 new autoantigens, low-density lipoprotein receptor-related protein (LRP4), agrin, collagen Q, and cortactin, located at the neuromuscular junction, have been identified. Clinical electrophysiology shows decremental response on repetitive nerve stimulation or increased jitter on single-fibre study. Present with muscle weakness which worsens with continued activity (fatiguability) and improves on rest. Severity varies from isolated eye muscle weakness to generalised muscle weakness and respiratory failure requiring mechanical ventilation. Risk factors: - FHx of autoimmune disorders - Genetic markers - Cancer-targeted therapy

Answer 102

Approximately 15% to 20% of patients may experience a myasthenic crisis (exacerbation necessitating mechanical ventilation). The estimated prevalence of myasthenia gravis is approximately 20 cases per 100,000 population, with the disease affecting twice as many women as men. The overall prevalence is approximately 150-200 per million. However, in older age groups, men are affected more often and the disease is often misdiagnosed

Answer 103

- Muscle fatiguability - Ptosis - Diplopia - Dysphagia - Dysarthria - Facial paresis - Proximal limb weakness - Shortness of breath - Disturbed hypernasal speech - Difficulty smiling, chewing or swallowing - nasal regurgitation of fluids

Answer 104

- Generalised, bulbar or ocular. EYES - Bilateral ptosis - Asymmetrical - Complex opthalmoplegia - Watch for progressive ptosis - 'Ice on eyes' test - improves NM transmission, reducing ptosis by >2mm from baseline BULBAR - Reading aloud provokes dysarthria or nasal speech after 3 minutes Limbs - Test power of muscle before and after repeated use of the muscle - e.g. 20 repetitions

Answer 105

1st line: - Serum AChR antibody analysis - titre above a certain point - MuSK antibodies - may be positive - Serial pulmonary function tests - MG crisis low FVC and NIF Consider: - Striational antibodies - positive - Repetitive nerve stimulation - >10 % decline in CMAP amplitude between 1st and 4th potential in a train of 10 stimulations at 2-3Hz - Single-fibre EMG - increase variability in motor latencies (jitter) or complete failure of NM (block) in some muscle fibres - CT of chest - thymic enlargement

Answer 106

Rapid permanent neurological deficit from cerebrovascular insult. Focal or global impairment of CNS function developing rapidly and lasting >24h.

Answer 107

INFARCTION (80%) - Thrombosis - lacunar and large vessel atherosclerosis, prothrombotic states - Emboli - intimal flap of carotid dissection, atherosclerosis in carotids, heart pathology (AFib, right-left heart defect) - Hypotension - If below the autoregulatory range maintaining cerebral blood flow, infarction results in watershed zones between different cerebral artery territories - Vasculitis - Cocaine ``` HAEMORRHAGE (10%) - Hypertension - Charcot-Bouchard microaneurysm rupture - Amyloid angiopathy - AV malformation Trauma - Tumours - Vasculitis ``` Ischaemic brain becomes soft due to vasogenic oedema from breakdown of BBB and prone to haemorrhagic transformation - secondary damage to CNS.

Answer 108

2/1000. Common. 3rd most common cause of death in industrialized countries. 70yrs + most patients. Young stroke (<50) merit extensive investigations.

Answer 109

Sudden onset - deterioration within seconds. - Weakness, sensory, visual or cognitive impairment - Impaired coordination - Impaired conscioussness - Head and neck pain in carotid or vertebral artery dissection - Enquire time of onset as critical for management (if <4.5h) - Enquire if history of atrial fibrillation, MI, valvular heart disease, carotid artery stenosis, recent neck trauma or pain

Answer 110

Examine for underlying cause -e.g. AFib, heart murmurs, carotid bruit, fundoscopy. ANTERIOR CIRCULATION - Anterior cerebral = lower limb weakness (motor cortex), confusion (frontal lobe) - Middle cerebral = facial weakness, hemiparesis (motor cortex), hemisensory loss (somatosensory cortex), apraxia, hemineglect (parietal lobe), receptive or expressive dysphasia (language centres), quadrantanopia (superior or inferior optic radiations) SMALL VESSELS (LACUNAR) - Internal capsule or pons = pure sensory or motor deficit, or combination of both - Thalamus = LOC, hemisensory deficit - Basal ganglia = hemichorea, hemiballismus, parkinsonism POSTERIOR CIRCULATION - Posterior cerebral = hemianopia - Anterior inferior cerebellar artery = vertigo, ipsilateral ataxia, ipsilateral deafness (or tinnitus), ipsilateral facial weakness - Posterior inferior cerebellar artery (lateral medullary syndrome of Wallenberg) = vertigo, ipsilateral ataxia, ipsilateral Horner's syndrome, ipsilateral hemifacial sensory loss, dysarthria and contralateral spinothalamic sensory loss - Basilar artery - combination of cranial nerve pathology, impaired consciousness (emergency) MULTIPLE LACUNAR INFARCTS - Vascular dementia - Urinary incontinence - Gait apraxia - marche a petits pas - Shuffling small-stepped gait - Upright posture - Normal or excessive arm-swing HAEMORRHAGE - Intracerebral = headache, meningism, focal neurological signs, N&V, signs of raised ICP, seizures - Subarachnoid

Answer 111

1. Bloods 2. ECG - identify arrhythmias 3. Echo - identify source of embolism (bubble contrast for right-to-left shunt) 4. Carotid Doppler - exclude carotid artery disease 5. CT Head - see haemorrhages, normal in lacunar infarct or <6h into stroke 6. MRI brain - higher sensitivity, diffusion-weighted imaging to determine whether recent or old 7. CT-Cerebral Angiogram - detect dissections or intracranial stenosis (MRA with T1-fat-saturation useful alternatively) Bloods - FBC - U&E - Glucose - Clotting profile - Lipids - Thrombophilia screen ISCHAEMIC STROKE 1st line: - Non-contrast CT head - if indications for thormbolysis or thrombectomy, on anti-coag / bleeding tendency, GCS <13, raised ICP, severe headache Result: Hypoattenuation (dark in brain parenchyma), loss of grey matter-white matter differentiation, sulcal effacement, hyperattenuation (brightness) in artery (clot) - Glucose - normal, hypoglycaemia (stroke mimic), hyperglycaemia (bleeding, worse outcomes) - Electrolytes - normal - Urea & Creatinine - normal, renal failure - Cardiac enzymes - normal, cardiac ischaemia - FBC - normal, anaemia, thrombocytopenia - ECG - may show arrhythmia or signs of ischaemia - PT/PTT with INR - normal, coagulopathy HAEMORRHAGIC STROKE - Non-contrast CT head - if indications for thormbolysis or thrombectomy, on anti-coag / bleeding tendency, GCS <13, raised ICP, severe headache Result: Hyperattenuation, suggesting acute blood surrounding hypoattenuation due to oedema. - Glucose - normal, hypoglycaemia (stroke mimic), hyperglycaemia (intracerebral bleeding risk) - Electrolytes - normal - Urea and Creatinine - normal, renal failure - LFTs - normal, liver dysfunction (bleeding risk) - FBC - normal, anaemia, thrombocytopenia - Clotting screen - normal or high INR / FXa levels - ECG - normal, arrhythmia or signs of ischaemia

Answer 112

SUSPECTED ISCHAEMIC STROKE - A to E approach - ET intubation GCS <8, Oxygen if Sats <93% - Admit to hyperacute stroke unit within 4 hours of presentation - swallow assessment, nutrition support CONFIRMED ISCHAEMIC STROKE Within 4.5 hours + Thrombolysis IS NOT contraindicated (Must exclude intracerebral haemorrhage by imaging first) - Supportive care + monitoring - GCS, blood glucose 4-11mmol/L, BP <185/110mmHg, O2 if Sats <93%, hydration, temperature, ECG monitoring, ICP (low LOC, headache, N&V, high BP), seizures - Alteplase IV - Consider mechanical thrombectomy (endovascular intervention) - Antiplatelet agent - 24h after alteplase, give aspirin or clopidogrel daily for 2 weeks - VTE prophylaxis - intermittent pneumatic compression, NOT LMWH or Teds - Early mobilization - High-intensity statin - atorvastatin given after 48h Outside 4.5 hours OR Thrombolysis IS contraindicated - Supportive care + monitoring - Mechanical thrombectomy (endovascular intervention) - Anti-platelet agent - give aspirin or clopidogrel daily for 2 weeks - VTE prophylaxis - intermittent pneumatic compression, NOT LMWH or Teds - Early mobilization - High-intensity statin - atorvastatin given after 48h SUSPECTED HAEMORRHAGE - A to E approach - ET intubation GCS <8, Oxygen if Sats <93% - Admit to hyperacute stroke unit within 4 hours of presentation - swallow assessment, nutrition support CONFIRMED HAEMORRHAGE - Supportive care plus monitoring - GCS, glucose 4-11 mmol/L, BP, O2, hydration, temperature, cardiac monitoring, ICP (haematoma mass effect, transtentorial herniation, intraventricular haemorrhage, hydrocephalus), seizures - Immediate referral for neurosurgery assessment - medical management for small deep haemorrhages, lobar haemorrhages without hydrocephalus or neurological deterioration, large haemorrhage and comorbidities, posterior fossa haemorrhage, GCS <8 unless hydrocephalus - Rapid blood pressure control - aim for 130-140 SBP mmHg for 7 days within 1h of starting treatment - Urgent reversal of anticoagulation Warfarn/Vit K antagonist = PCC AND Phytomenadione Dabigatran = Idarucizumab Factor Xa Inhibitor = PCC - VTE prophylaxis - intermittent pneumatic compression, NOT LMWH or Teds - Early mobilisation SECONDARY PREVENTION - Aspirin - Dipyridamole - Warfarin (if AFib) - Stop smoking - Control hypertension and hyperlipidaemia - Treatment of carotid artery disease

Answer 113

- Cerebral oedema - raised ICP and local compression - Immobility - Infections - e.g. pneumonia, UTI, pressure sores - DVT - Cardiovascular events - e.g. arrhythmias, MI, cardiac failure - Death

Answer 114

10% mortality in first months. Up to 50% of those who survive remain dependent. 10% recurrence in 1 year. Poorer for haemorrhages than infarction.

Answer 115

An autosomal-dominant genetic disorder with defining features of: - Cafe au lait spots - Multiple neurofibromas - Iris Lisch nodules

Answer 116

RNA-based NF1 mutation = TYPE 1. Additional manifestations involving: - Skin - CNS - Peripheral nerves - Bones - GI tract - Vasculature - Endocrine system Most common: - Learning disabilities - optic pathway gliomas - Diffuse plexiform neurofibromas - Dystrophic scoliosis - Sphenoid wing dysplasia - Renovascular hypertension - Malignant peripheral nerve sheath tumours Risk factors: - Parent with NF 1 - Severe crush trauma

Answer 117

Progressive, variable but will worsen.

Answer 118

- Family history of NF1 - Pain, any location - Compromised vision - Compromised social interactions NEUROLOGICAL - Gross motor delay - General inco-ordination - School performance problems - Autosim spectrum disorder SKIN - Cafe au lait - Axillary freckling - Cuteanous juvenile xanthogranuhlomas - Neurofibromas HEAD & NECK - Unilateral diffuse plexiform neurofibroma divisions of trigeminal nerve - Visual compromise - Optic disc pallor - Iris Lisch nodules CNS - Signs of hydrocephalus - Brain tumours - Cerebellar abnormalities PNS - Palpable mass about neck - Brachial plexuses - Groin - Hunter's canal - Popliteal fossae SKELETAL - Tibial dysplasia - Pseudoarthrosis - Sphenoid wing dysplasia - Pectus excavatum or carinatum - Genu valgum or varum - Ankle valgus - Pes planus GI - Severe constipation - Obstipation - Abdominal pain - GI bleeding Vascular - Neurological problems - Abdominal pain - Haemorrhage

Answer 119

- Family history of NF1 - Pain, any location - Compromised vision - Compromised social interactions NEUROLOGICAL - Gross motor delay - General inco-ordination - School performance problems - Autosim spectrum disorder SKIN - Cafe au lait - Axillary freckling - Cuteanous juvenile xanthogranuhlomas - Neurofibromas HEAD & NECK - Unilateral diffuse plexiform neurofibroma divisions of trigeminal nerve - Visual compromise - Optic disc pallor - Iris Lisch nodules CNS - Signs of hydrocephalus - Brain tumours - Cerebellar abnormalities PNS - Palpable mass about neck - Brachial plexuses - Groin - Hunter's canal - Popliteal fossae SKELETAL - Tibial dysplasia - Pseudoarthrosis - Sphenoid wing dysplasia - Pectus excavatum or carinatum - Genu valgum or varum - Ankle valgus - Pes planus GI - Severe constipation - Obstipation - Abdominal pain - GI bleeding Vascular - Neurological problems - Abdominal pain - Haemorrhage

Answer 120

1st Line; - MRI and/or CT scans - optic pathway gliomas, brain tumours, hydrocephalus, paraspinal neurofibromas, MPNSTs - PET scan - optic pathway gliomas, brian tumours, hydrocephalus, paraspinal neurofibromas, MPNSTs - Biopsy - features of neurofibroma or MPNST - Genetic testing to confirm NF1 mutation - identify NF1 locus

Answer 121

A neurodegenerative disorder. - Resting tremor - Rigidity - Bradykinesia - Postural instability

Answer 122

Loss of darkly pigmented area in substantia nigra pars compacta (SNpc) and locus coeruleus. Death of dopaminergic neuromelanin-containing neurones in SNpc. Death of noradrenergic neurones in locus coeruleus. Denervation of nigrostriatal pathway, resulting in diminished dopamine levels in striatum. Risk factors: - Increasing age - History of familial PD in younger-onset disease - Mutation in gene eoncoding glucocerebrosidase - 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) exposure - Chronic exposure to metals (manganese, iron) - Male sex - Genetic risk factors - Head trauma - Geographic influence (rural living) - Toxin exposure - Occupation as a teacher, healthcare provider, construction worker, carpenter or cleaner

Answer 123

Insidious, often asymmetrical, onset. Parkinson's disease (PD) affects 1-2 per 1000 of the population at any time. PD prevalence is increasing with age and PD affects 1% of the population above 60 years.

Answer 124

BRADYKINESIA RESTING TREMOR RIGIDITY POSTURAL INSTABILITY Others: - Masked facies - loss of sponatenous facial movement and expressivity - Hypophonia - Hypokinetic dysarthria - Micrographia - Stooped postrue - Shuffling gait - Conjugate gaze disorders - Fatigue - Constipation - Depression - Anxiety - Dementia

Answer 125

BRADYKINESIA RESTING TREMOR RIGIDITY POSTURAL INSTABILITY Others: - Masked facies - loss of sponatenous facial movement and expressivity - Hypophonia - Hypokinetic dysarthria - Micrographia - Stooped postrue - Shuffling gait - Conjugate gaze disorders - Fatigue - Constipation - Depression - Anxiety - Dementia

Answer 126

1st Line: - Dopaminergic agent trial - improvement in symptoms after levodopa Consider: - MRI brain - age-related changes (mild small vessel disease), advanced changes (cortical atrophy, no dorsolateral nigral hyperintensity - swallow-tail-sign absent) - Functional neuroimaging - decreased basal ganglia (putaminal) pre-synaptic dopamine uptake - Olfactory testing -hyposmia or anosmia - Genetic testing - Neuropsychometric testing - executive dysfunction in PD with dementia - Serum ceruloplasmin - low in Wilson's (if patient < 40 years) - 24-hour urine copper - high in Wilson's (if patient < 40 years) - Brain pathology (postmortem) - nigrostriatal degeneration, Lewy bodies

Answer 127

CAN BE ACUTE OR CHRONIC. CAUSED BY: - Localised mass lesions - Disturbance of CSF circulation - Obstruction to major venous sinuses - Diffuse brain oedema or swelling - Idiopathic DIFFERENTIALS: - Trauma - extradural, subdural, intracerebral - Subarachnoid haemorrhage - Neoplasms - glioma, meningioma, mets - Abscess - Focal oedema (trauma, infarction, tumour) - Obstructive hydrocephalus - Communicating hydrocephalus - Depressed fractures overlying major venous sinuses - Central venous thrombosis - Encephalitis - Meningitis - Reye's syndrome - Lead encephalopathy - Water intoxication - Near drowning - Benign intracranial hypertension The skull is considered as an enclosed and inelastic container. An increase in the volume of any one of the intracranial contents must be offset by a decrease in one or more of the others or be associated with a rise in ICP. Intracranial blood (especially in the venous compartment) and CSF are the two components whose volume can adapt most easily to accommodate an increase in the volume of intracranial contents. Once these compensatory mechanisms are exhausted, further increases in volume result in large rises in ICP.

Answer 128

HEADACHE PAPILLOEDEMA VOMITING Headache - Throbbing or bursting - Worsened by coughing, sneezing, recumbency or exertion - Worse in the morning Papilloedema - Several days to develop Vomiting - Late feature - After waking - Accompanies morning headache LOC - Progressive deterioration - Consequence of caudal displacement of diencephalon and midbrain

Answer 129

- Progressive loss of consciousness - Papilloedema - Pupillary dilatation - Bilateral ptosis - Impaired upgaze - Extension to pain - Respiratory irregularity - Diplopia (Mainly due to tentorial or tonsillar herniation) - Tensed cranial fontanelle - Seizures - Hypertension - Bradycardia - Respiratory depression

Answer 130

- CT/MRI - determine lesion - Blood glucose - Renal function - Electrolytes - Osmolality - ICP monitoring - if GCS 3-8 after CPR + abnormal head CT

Answer 131

Results from processes that compress or displace arterial, venous and CSF spaces, as well as the cord itself. ACUTE SPINAL CORD COMPRESSION IS A MEDICAL EMERGENCY.

Answer 132

EXTRINSIC OR INTRINSIC. E.g. - Trauma or tumour affecting cord substance - Lesions that compromise cord function emanating from surrounding elements or vascular sources - Vertebral compression fracture - Intervertebral disc herniation - Primary or mets spinal tumour - Infection MAY BE ACUTE, SUB-ACUTE OR CHRONIC. - Due to direct cord damage - Due to compression - Due to infiltration - Due to compromise of vascular supply to cord Symptoms due to spinal cord injury or root dysfunction. Risk factors: - Between 16-30 years - Male - Trauma - Tumour - Osteoporosis - High-risk occupation - e.g. construction, agricultural, seamen, bricklayers, road menders, vehicle drivers, military, law enforcement, firefighters - High-risk recreational activities - vehicle racing, mountaineering, diving, horse riding, gymnastics - IV drug use - Immunosuppression

Answer 133

The annual incidence rates of spinal cord compression due to trauma is estimated approximately to be 8-246 cases per 100,000 population. The annual incidence rates of spinal cord compression due to cancer-related in the US is approximately 20,000.

Answer 134

AGE GROUP - 16-30 = trauma - 30-50 = disc disease - 40-75 = malignancy Symptoms: - Acute or chronic onset and duration of symptoms - Back pain - Numbness or paraesthesias - Weakness or parlysis - Bladder or bowel dysfunction - Hyper-reflexia (UMN) - Sensory loss - Muscle weakness or wasting - Loss of tone below level of suspected injury (spinal shock) - Hypotension and bradycardia - neurogenic shock COMPLETE CORD TRANSECTION SYNDROME - Quadriplegia - Respiratory insufficiency - Loss of bladder and bowel function - Anaesthesia below affected level - Neurogenic shock - hypotension and hypothermia - Horner's - miosis, anhidrosis, ipsilateral ptosis - Lower cervical transection spares respiratory muscles CAUDA EQUINA SYNDROME - Disc compression and stenosis of spinal canal - Saddle (perineal) anaesthesia - Bladder retention - Leg weakness CENTRAL CORD SYNDROME - Hyperextension injury association - More in older people - Loss of upper limb function compared to lower limbs - includes vestibulospinal tract

Answer 135

AGE GROUP - 16-30 = trauma - 30-50 = disc disease - 40-75 = malignancy Symptoms: - Acute or chronic onset and duration of symptoms - Back pain - Numbness or paraesthesias - Weakness or parlysis - Bladder or bowel dysfunction - Hyper-reflexia (UMN) - Sensory loss - Muscle weakness or wasting - Loss of tone below level of suspected injury (spinal shock) - Hypotension and bradycardia - neurogenic shock COMPLETE CORD TRANSECTION SYNDROME - Quadriplegia - Respiratory insufficiency - Loss of bladder and bowel function - Anaesthesia below affected level - Neurogenic shock - hypotension and hypothermia - Horner's - miosis, anhidrosis, ipsilateral ptosis - Lower cervical transection spares respiratory muscles CAUDA EQUINA SYNDROME - Disc compression and stenosis of spinal canal - Saddle (perineal) anaesthesia - Bladder retention - Leg weakness CENTRAL CORD SYNDROME - Hyperextension injury association - More in older people - Loss of upper limb function compared to lower limbs - includes vestibulospinal tract

Answer 136

1st Line: - MRI spine - disc displacement, epidural enhancement, mass effect, T2 cord signal - Gadolinium-enhanced MRI spine - infection (epidural space and bone involvement), mets (visualise tumour) - Plain spine XR - decreased disc space height (disc compression), loss of bony detail (tumour, infection), misalignment of vertebral elements (trauma), loss of end-plate definitions (infection) - CT spine - cord compression from tumour expansion into canal or bony fragments from pathological fracture - CT myelography - classical hour-glass constriction shape of dye column Consider: - FBC with differential - high WCC with neutrophilia in infection - ESR/ CRP - high in infection or inflammation (osteomyelitis, epidural abscess) - Blood or CSF cultures - positive in epidural abscess, discitis or osteomyelitis - Tumour biopsy and histopathology - tissue diagnosis of malignancy - Urodynamic studies - reduced bladder contractility sphincter dysfunction - PET scan - areas of hypermetabolism detected

Answer 137

A facial pain syndrome in the distribution of >1 divisions of the trigeminal nerve.

Answer 138

Causes: - Paraneoplastic aetiologies - Vascular causes - e.g. pontine infarct, AV malformation, aneurysm - Inflammatory causes - MS, sarcoidosis, Lyme disease neuropathy Risk factors: - Increased age - MS - Female - Hypertension

Answer 139

Trigeminal neuralgia (TN) has a prevalence of 0.1-0.2 per thousand and an incidence ranging from about 4-5/100,000/year up to 20/100,000/year after age 60. The female-to-male ratio is about 3:2.

Answer 140

- Paroxysms of sharp, stabbing, intense pain - Last up to 2 minutes - Can be constant component of facial pain - Without associated neurological deficit - Pain precipitated by trigger areas or factors - Repeated attacks are typically stereotyped in the individual

Answer 141

- Paroxysms of sharp, stabbing, intense pain - Last up to 2 minutes - Can be constant component of facial pain - Without associated neurological deficit - Pain precipitated by trigger areas or factors - Repeated attacks are typically stereotyped in the individual

Answer 142

1st Line: - No first test Consider: - Intra-oral XR - no dental cause of pain found - e.g. dental caries, dental fracture, osteomyelitis - MRI - may demonstrate presence of abnormal vessel loop in association with trigeminal nerve, or tumour, infarct, MS plaque - Trigeminal reflex testing - early blink reflex or early masseter inhibitory reflex

Answer 143

A neurological emergency resulting from thiamine deficiency with varied neurocognitive manifestations, typically involving mental status changes and gait and oculomotor dysfunction.

Answer 144

Caused by acute deficiency of thiamine in a susceptible host. Risk factors: - Alcohol dependence - AIDS - Cancer and treatment with chemotherapeutic agents - Malnutrition - History of GI surgery - Genetics - Bone marrow transplantation - Infants who have been fed formula milk deficient in thiamine - Male sex

Answer 145

Although easily preventable, Wernicke's encephalopathy (WE) remains a regrettably frequent and largely undiagnosed disorder in alcoholics. Unselected autopsy materials from the United States and Australia give prevalence figures of 2%. In Oslo, Norway, the corresponding figures are somewhat lower, 0.6%-0.8%.

Answer 146

TRIAD: - CONFUSION - ATAXIA - NYSTAGMUS - OPTHALMOPLEGIA Diagnostic factors: - History of GI surgery - Mental slowing - Impaired concentration - Apathy - Frank confusion - Ocular motor findings - gaze palsies, 6th nerve palsies, impaired vestibulo-ocular reflexes - Mental status changes - Opthalmoplegia - Gait dysfunction - Mild irritability - Delirium - Acute psychosis

Answer 147

TRIAD: - CONFUSION - ATAXIA - NYSTAGMUS - OPTHALMOPLEGIA Diagnostic factors: - History of GI surgery - Mental slowing - Impaired concentration - Apathy - Frank confusion - Ocular motor findings - gaze palsies, 6th nerve palsies, impaired vestibulo-ocular reflexes - Mental status changes - Opthalmoplegia - Gait dysfunction - Mild irritability - Delirium - Acute psychosis

Answer 148

1st line: - Trial of parenteral thiamine - clinical response to treatment (thiamine level obtained before administration) - Finger-prick glucose - normal unless co-existent conditions (alcoholic liver disease, acute alcohol intoxication, sepsis, hypotension) - FBC - normal unless WCC due to infection - Serum electrolytes - normal, abnormal if not treated or in late-presenting disease - Renal function -normal, abnormal if not treated or in late-presenting disease - LFTs- elevated if history of chronic alcohol misuse or hypotension - Urinary and serum drug screen - negative - Serum ammonia - normal unless decompensation of co-existent alcoholic liver disease - Blood alcohol level - high if alcohol misuse - Blood thiamine and its metabolites - while the blood thiamine levels are usually low, the critical blood concentrations of thiamine for treating the condition have not been determined - Serum magnesium - may be low in alcohol misuse Consider: - LP - normal (exclude other pathology) - MRI - involvement of mammillary bodies, dorsomedial nucleus of thalami, periaqueductal grey matter, floor of 4th ventricle, cerebellar vermis - CT - bilateral low-density thalamic lesions, low density areas around aqueduct / 3rd ven / fornices

Answer 149

Episodic or chronic. Stress and mental tension are common triggers. Usually do not seek medical care, self-treat. Risk factors: - Mental tension - Stress - Missing meals - Fatigue - Somatisation - Female - Age 20-39 years - Lower socioeconomic status - Analgesic overuse

Answer 150

Most common type of headache.

Answer 151

- Dull - Non-pulsatile - Bilateral - Constricting pain (not severe) - Pericranial tenderness - Frontal and occipital regions - Tight band around the head - Doesn't worsen with routine physical activity (unlike migraine) - No N&V

Answer 152

Normal neurological examination. ``` Pericranial tenderness. Sternocleidomastoid muscle tenderness. Trapezius muscle tenderness. Temporalis muscle tenderness. Lateral pterygoid muscle tenderness. Masseter muscle tenderness. ```

Answer 153

1stline: - Clinical diagnosis Consider: - CT sinus- normal - exclude sphenoid sinusitis - MRI brain - normal - exclude brain tumour - Lumbar puncture - normal - consider excluding infective causes, sinus venous thrombosis, pseudotumour cerebri

Answer 154

ACUTE ATTACK - Simple analgesics - aspirin, paracetmol, ibuprofen, naproxen CHRONIC - 7-9 headache days / months - Antidepressants - amitriptyline, doxepin, venlafaxine, mirtazapine - Non-drug therapies - EMG biofeedback, relaxation training, CBT, myofascial trigger point-focused massage, acupuncture, spinal manipulation, physiotherapy, hypnosis - Muscle relaxants - tizanidine

Answer 155

- Overreliance on non-prescription caffeine containing analgesics - Dependence on narcotic analgesics - GI bleed or peptic ulcer from NSAIDs - Risk of epilepsy x4 than general population - Medication overuse headache

Answer 156

Tension-type headaches (TTH) may be painful, but are not harmful. Most cases are intermittent and do not interfere with work or normal life span. However, they may become chronic if life stressors are not changed.

Answer 157

A transient episode of neurological dysfunction caused by focal brain, spinal cord or retinal ischaemia without acute infarction.

Answer 158

Risk factors: - Atrial fibrillation - Valvular disease - Carotid stenosis - CHF - Hypertension - DM - Cigarette smoking - Alcohol-use disorder - Advanced age - Hyperlipidaemia - Patent foramen ovale - Inactivity - Obesity - Hypercoagulability

Answer 159

The incidence likely mirrors that of stroke. The incidence of TIAs increases with age, from 1-3 cases per 100,000 in those younger than 35 years to as many as 1500 cases per 100,000 in those older than 85 years. Fewer than 3% of all major cerebral infarcts occur in children

Answer 160

- Sudden onset - Few minutes to 24 hours - Usually complete resolution of symptoms and signs within 1 hour - Patient / witness report of focal neurological deficit - Vertigo - Loss of balance - Sudden transient loss of vision in one eye - amaurosis fugax

Answer 161

- Unilateral weakness or paralysis - Dysphasia - Ataxia - Homonymous hemianopia - Diplopia - Risk factors

Answer 162

1st line: - Blood glucose - exclude hypoglycaemia - FBC - exclude infection - Platelet count - exclude infection - PT time - normal unless already on anticoagulation, liver disease or antiphospholipid antibodies - INR - normal unless already on anticoagulation, liver disease or antiphospholipid antibodies - Partial thromboplastin time - normal unless already on anticoagulation, liver disease or antiphospholipid antibodies - Fasting lipid profile - baseline measure, evaluate atherosclerotic factors - Serum electrolytes - exclude electrolyte disturbance cause - ECG - may show atrial fibrillation, arrythmias or MI Consider: - URGENT CT scan - in patients taking anticoagulant or with bleeding disorder to exclude haemorrhage

Answer 163

SUSPECTED - Antiplatelet therapy - aspirin, clopidogrel 300mg orally as loading dose - PPI given if dyspepsia - Specialist assessment CONFIRMED - Antiplatelet therapy - clopidogrel (better for long-term secondary prevention), aspirin 75mg orally OD - PPI given if dyspepsia - High intensity statin - atorvastatin - Anticoagulant for AFib after excluding intracranial bleeding - e.g. LMWH or direct thrombin inhibitor or factor Xa inhibitor (non-valvular AFib)

Answer 164

Suspect a stroke if sudden-onset, focal neurological deficit persists for longer than 24 hours and cannot be explained by another condition such as hypoglycaemia. Generally do not cause permanent brain damage, but are a serious warning sign.

Answer 165

Recurrent risk of stroke is high in first 7 days following a TIA. With passive reporting, the early risk of stroke after TIA is approximately 4% at 2 days, 8% at 30 days, and 9% at 90 days. When patients with TIA are followed prospectively, however, the incidence of stroke is as high as 11% at 7 days. The probability of stroke in the 5 years following a TIA is reported to be 24-29%